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PHYSIO  August 2002

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Subject:

Shock Wave Therapy

From:

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Reply-To:

- for physiotherapists in education and practice <[log in to unmask]>

Date:

Tue, 27 Aug 2002 16:00:16 EDT

Content-Type:

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For those who may not heard of a relatively new form of physical therapy,
here is some information on what has come to be known as "shock wave
therapy".  Shock wave therapy (ESWT) for treating musculoskeletal injuries
involves the application of mechanical vibration in the form of pulsed
acoustic (sound) waves. Since the 1990s reports of benefit of ESWT in the
treatment of tendon disorders have been appearing in the literature. Here is
a selection of abstracts on this topic:

-----------

J Bone Joint Surg Am 2002 Mar; 84-A(3):335-41

Evaluation of low-energy extracorporeal shock-wave application for treatment
of chronic plantar fasciitis.

Rompe JD, Schoellner C, Nafe B.

BACKGROUND: Although the application of low-energy extracorporeal shock waves
to treat musculoskeletal disorders is controversial, there has been some
limited, short-term evidence of its effectiveness for the treatment of
chronic plantar fasciitis.

METHODS: From 1993 to 1995, a prospective, two-tailed, randomized,
controlled, observer-blinded pilot trial was performed to assess whether
three applications of 1000 impulses of low-energy shock waves (Group I) led
to a superior clinical outcome when compared with three applications of ten
impulses of low-energy shock waves (Group II) in patients with intractable
plantar heel pain. The sample size was 112. The main outcome measure was
patient satisfaction according to a four-step score (excellent, good,
acceptable, and poor) at six months. Secondary outcome measures were patient
satisfaction according to the four-step score at five years and the severity
of pain on manual pressure, at night, and at rest as well as the ability to
walk without pain at six months and five years.

RESULTS: At six months, the rate of good and excellent outcomes according to
the four-step score was significantly (47%) better in Group I than in Group
II. As assessed on a visual analog scale, the score for pain caused by manual
pressure at six months had decreased to 19 points, from 77 points before
treatment, in Group I, whereas in Group II the ratings before treatment and
at six months were 79 and 77 points. In Group I, twenty-five of forty-nine
patients were able to walk completely without pain at six months compared
with zero of forty-eight patients in Group II. By five years, the difference
in the rates of good and excellent outcomes according to the four-step score
was only 11% in favor of Group I because of a high rate of good and excellent
results from subsequent surgery in Group II; the score for pain caused by
manual pressure had decreased to 9 points in Group I and to 29 points in
Group II. At five years, five (13%) of thirty-eight patients in Group I had
undergone an operation of the heel compared with twenty-three (58%) of forty
patients in Group II.

CONCLUSIONS: Three treatments with 1000 impulses of low-energy shock waves
appear to be an effective therapy for plantar fasciitis and may help the
patient to avoid surgery for recalcitrant heel pain. In contrast, three
applications of ten impulses did not improve symptoms substantially.

-------------

Cochrane Database Syst Rev 2002;(1):CD003524

Shock wave therapy for lateral elbow pain.

Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJ.

BACKGROUND: This review is one in a series of reviews of interventions for
lateral elbow pain. Lateral elbow pain, or tennis elbow, is a common
condition causing pain in the elbow and forearm and lack of strength and
function of the elbow and wrist. Shock wave therapy (ESWT) involves the
application of single pulsed acoustic wave. Since the 1990's reports of
benefit of ESWT in the treatment of tendon disorders have been appearing in
the literature. A systematic review published in the German language appeared
in 2000 (Boddeker 2000)

OBJECTIVES: To determine the effectiveness and safety of ESWT in the
treatment of adults with lateral elbow pain. SEARCH STRATEGY: Comprehensive
electronic searches of MEDLINE, CINAHL, EMBASE and SCISEARCH were combined
with searches of the Cochrane Clinical Trails Registrar and the
Musculoskeletal Review Group's specialist trial database. Identified keywords
and authors were searched again in an effort to identify as many trials as
possible.

SELECTION CRITERIA: Two independent reviewers assessed all identified trials
against pre-determined inclusion criteria. Randomised and pseudo randomised
trials in all languages were evaluated for inclusion in the review provided
they described individuals with lateral elbow pain and were comparing the use
of ESWT as a treatment strategy.

DATA COLLECTION AND ANALYSIS: For continuous variables means and standard
deviations were extracted or imputed to allow the analysis of weighted mean
difference. Weighted mean difference using a random effects model was
selected when outcomes were measured on standard scales. A fixed effects
model was used to interpret results and assess heterogeneity. For binary data
numbers of events and total population were analysed and interpreted as
relative risk.

MAIN RESULTS: Two trials of ESWT versus placebo are included in this review
(Rompe 1996, Haake 2001). Both trials included similar study populations
consisting of participants with chronic symptoms who had failed other
conservative treatment. The frequency of ESWT application and the doses and
techniques used were similar in both trials. The first trial demonstrated
highly significant differences in favour of ESWT whereas the second trial
found no benefits of ESWT over placebo. When the data from the two trials
were pooled, the benefits observed in the first trial were no longer
statistically significant. The relative risk for treatment failure (defined
as Roles-Maudsley score of 4) of ESWT over placebo was 0.40 (95% CI, 0.08 to
1.91) at six weeks and 0.44 (95% CI, 0.09 to 2.17) at one year. After 6
weeks, there was no statistically significant improvement in pain at rest
[WMD pain out of 100 = - 11.40 (95% CI, -26.10 to 3.30)], pain with resisted
wrist extension [WMD pain out of 100 = -16.20 (95% CI, -47.75 to 15.36)] or
pain with resisted middle finger extension [WMD pain out of 100 = -20.51(95%
CI, -56.57 to 15.56)]. Results after 12 or 24 weeks were similar.

REVIEWER'S CONCLUSIONS: The two trials included in this review yielded
conflicting results. Further trials are needed to clarify the value of ESWT
for lateral elbow pain.

----------------

Z Orthop Ihre Grenzgeb 2002 May-Jun;140(3):267-74

[Musculoskeletal shock wave therapy - current database of clinical research]

Rompe JD, Buch M, Gerdesmeyer L, Haake M, Loew M, Maier M, Heine J

During the past decade application of extracorporal shock waves became an
established procedure for the treatment of various musculoskeletal diseases
in Germany. Upt to now the positive results of prospective randomised
controlled trials have been published for the treatment of plantar fasciitis,
lateral elbow epicondylitis (tennis elbow), and of calcifying tendinitis of
the rotator cuff. Most recently, contradicting results of prospective
randomised placebo-controlled trials with adequate sample size calculation
have been reported. The goal of this review is to present information about
the current cinical database on extracorporeal shock wave tratement (ESWT).

-------------------

Clin Orthop 2001 Jun;(387):72-82

Shock wave therapy versus conventional surgery in the treatment of calcifying
tendinitis of the shoulder.

Rompe JD, Zoellner J, Nafe B.

A prospective quasirandomized study was performed to compare the effects of
surgical extirpation (Group I, 29 patients) with the outcome after
high-energy extracorporeal shock wave therapy (Group II, 50 patients; 3,000
impulses of an energy flux density of 0.6 mJ/mm2) in patients with a chronic
calcifying tendinitis in the supraspinatus tendon. Symptoms and demographic
data of the two groups were comparable. According to the University of
California Los Angeles Rating System, the mean score in Group I was 30 points
with 75% good or excellent results after 12 months, and 32 points with 90%
good or excellent results after 24 months.

Radiologically, there was no calcific deposit in 85% of the patients after 1
year. In Group II, the mean score was 28 points with 60% good or excellent
results after 12 months, and 29 points with 64% good or excellent results
after 2 years. Radiologically, complete elimination of the deposit was
observed in 47% of the patients after 1 year. Clinically, according to the
University of California Los Angeles score, there was no significant
difference between both groups at 1 year. At 2 years, there was a
significantly better result in Group II. Both groups then were subdivided
into patients who had a homogenous deposit as seen on radiographs and
patients who had an inhomogenous deposit before treatment.

Surgery was superior compared with high-energy shock wave therapy for
patients with homogenous deposits. For patients with inhomogenous deposits,
high-energy extracorporeal shock wave therapy was equivalent to surgery and
should be given priority because of its noninvasiveness.

--------------------

Arch Orthop Trauma Surg 2002 May;122(4):222-8

Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of
tennis elbow.

Haake M, Boddeker IR, Decker T, et al

Apart from a few observational reports, there are no studies on the
side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of
insertion tendopathies. Within the framework of a randomised,
placebo-controlled, single-blind, multicentre study to test the effectiveness
of ESWT in the case of lateral epicondylitis (LE), side-effects were
systematically recorded. A total of 272 patients from 15 centres was
allocated at random to active ESWT (3 x 2000 pulses, energy flux density
ED(+) 0.04 to 0.22 mJ/mm(2) under local anaesthesia) or placebo ESWT. In all,
399 ESWT and 402 placebo treatments were analysed.

More side-effects were documented in the ESWT group (OR = 4.3, CI = [2.9;
6.3]) than in the placebo group. Most frequently, transitory reddening of the
skin (21.1%), pain (4.8%) and small haematomas (3.0%) were found. Migraine
was registered in four and syncopes in three instances after ESWT. ESWT for
LE with an energy flux density of ED(+) 0.04 to 0.22 mJ/mm(2) is a treatment
method which has very few side-effects. The possibility of migraine being
triggered by ESWT and the risk of a syncope should be taken into account in
the future. No physical shock wave parameters could be definitely identified
as the cause of the side-effects observed.

------------------

Clin Orthop 2001 Jun;(387):102-11

High-energy extracorporeal shock wave treatment of nonunions.

Rompe JD, Rosendahl T, Schollner C, Theis C.

Forty-three consecutive patients who did not have healing of tibial or
femoral diaphyseal and metaphyseal fractures  and osteotomies for at least 9
months after injury or surgery were examined prospectively for use of
high-energy  extracorporeal shock waves. Former treatment modalities (cast,
external fixator, plate osteosynthesis, limitation of  weightbearing)
remained unchanged. In all cases a 99mTechnetium dicarboxyphosphonate
regional two-phase bone  scintigraphy was performed before one treatment with
3,000 impulses of an energy flux density of 0.6 mJ/mm2.  Radiologic and
clinical followups were done at 4-week intervals starting 8 weeks after shock
wave treatment. The  success criterion was bridging of all four cortices in
the anteroposterior and lateral radiographic views, in oblique  views, or by
conventional tomography.

An independent observer described bony consolidation in 31 of 43 cases  (72%)
after an average of 4 months (range, 2-7 months). Twenty-nine of 35 (82.9%)
patients with a positive bone  scan had healing of the pseudarthrosis
compared with two of eight (25%) patients with a negative bone scan. Six of
these eight patients with negative scans were heavy smokers. No complications
were observed.

High-energy shock  wave therapy seemed to be an effective noninvasive tool
for stimulation of bone healing in properly selected patients  with a
diaphyseal or metaphyseal nonunion of the femur or tibia. Additional
controlled studies are mandatory.

--------------------

Dr Mel C Siff
Denver, USA
http://groups.yahoo.com/group/Supertraining/

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